Medical Management - Senior Manager Clinical Governance and Performance 145-2056

Job Summary

Required Qualifications

• •Demonstrated leadership ability within a health plan, managed care, or similarly regulated health care environment
• •Strong knowledge of Medicare Advantage and Marketplace regulatory and operational requirements for a health plan
• •Broad understanding of health plan operations, including utilization management, prior authorization, organization and coverage determinations, appeals, grievances, notices, delegation, and member and provider communications
• •Demonstrated experience with continuous audit readiness, internal auditing, delegated entity oversight, corrective action planning, policy and procedure management, training, and performance improvement
• •Ability to interpret complex regulatory, accreditation, contractual, and operational requirements and translate them into practical and sustainable processes
• •Strong analytical skills with the ability to identify trends, systemic risks, control gaps, root causes, and improvement opportunities
• •Ability to exercise authority and influence across multiple operational areas while maintaining collaborative relationships with functional leaders
• •Ability to distinguish regulatory requirements from organizational policy, clinical judgment, and operational preference
• •Well-developed written, verbal, interpersonal, facilitation, and presentation skills
• •Strong organizational and project management skills with the ability to manage competing priorities and regulatory deadlines
• •Ability to respectfully challenge existing practices, escalate concerns appropriately, and facilitate cross-functional resolutions
• •Demonstrated sound judgment, integrity, accountability, professionalism, and discretion
• •Successful completion of Health Care Sanctions background check
• •Successful completion of pre-employment drug testing
• •Ability to converse and write fluently in English
• •Bachelor's degree in health care administration, business administration, public health, nursing, compliance, pharmacy, quality, or a related field
• •Minimum of five years of progressive experience in health plan operations, utilization management, appeals and grievances, regulatory operations, auditing, accreditation, delegated oversight, performance improvement, or a related function
• •Minimum of three years of leadership or supervisory experience, including responsibility for staff performance, development, and accountability
• •Demonstrated experience supporting or leading CMS, URAC, state, delegated entity, client, or internal audit activities
• •Demonstrated experience developing or overseeing audit programs, corrective action plans, policies, procedures, training programs, or operational monitoring

Desired Qualifications

• •Experience with Medicare Advantage program audits, organization determinations, coverage determinations, appeals, grievances, reopening requirements, and delegated oversight strongly preferred
• •Experience with Marketplace requirements and URAC accreditation audits strongly preferred
• •Experience leading multidisciplinary teams or functions involving audit, training, policy management, administrative support, or process improvement preferred
• •Advanced degree or certification in health care administration, compliance, quality, audit, project management, or process improvement preferred